CLAHRC For South Yorkshire Measurably reducing excess winter

CLAHRC For South Yorkshire Measurably reducing excess winter deaths, illness and fuel poverty in populations

Unique selling point (USP) Strong multi-disciplinary team, combining scientific and economic expertise with experience working on the front line and strategically for the NHS, Department of Health, local government and the World Health Organization. Abacus team. Prof. Chris Bentley • Prof. Geoff Green • Jan Gilbertson • Catherine Homer • Dr. Paul Redgrave • Dr. Bernard Stafford • Prof. Angela Tod

In winter 2010/11 there were around 23, 700 ‘excess winter deaths’, or 1, 300 more people dying per week in the winter than the rest of the year Average of 144 Excess Winter Deaths per year 1990 -2010 in Rotherham, for example

The Threat of Winter DEA THH the Di sa bil it y ypo s es DEPRESSION lin ery ne xie ty Mis Lo An s e Illn s ts Acciden rmi a

Results Social Cost of Cold Homes e. g. in Sheffield 2011/12 £Million Premature Death Cardio Vascular Illness Respiratory Illness Falls at Home Common Mental Disorders Total Cost £ 1. 856 £ 1. 894 £ 1. 083 £ 0. 845 £ 9. 638 £ 15. 316 NHS Primary Secondary and Tertiary Cost plus Social Care Cost - £ 0. 462 £ 0. 497 £ 0. 250 £ 2. 112 £ 3. 321 GDP Loss - - £ 0. 934 Number of Cases 58 148 114 88 1 369 - Total Social Cost per Case £ 0. 0320 £ 0. 0159 £ 0. 0139 £ 0. 0124 £ 0. 0093 - Total Social Cost £ 1. 856 £ 2. 356 £ 1. 580 £ 1. 095 £ 12. 684 £ 19. 571 Loss of Well-Being

Producing Percentage Change at Population Level Producing Percentage Change at Population C. C. Bentley 2007

Intervention Through Services An Abacus proposal for an integrated programme of local action to pro-actively and systematically protect identifiable vulnerable people from avoidable illness and premature death

Abacus excess winter deaths and illness: capability and resilience model

The Challenge: To bring access to all the key 9 evidencebased interventions to as many vulnerable people as possible, in a systematic, rather than patchy process.

a) Coronary Heart Disease (Harison et al. 2006) b) Generic ‘Decay’ model (not to scale) Have the problem Eligible for intervention Aware of problem A B C Active use of systems Optimal input D

It is clear that, in trying to address the ‘decay’ in a population’s appropriate access to, and use of services, the role of individual services (such as medical GPs or Energy Sector companies) is essential, but not sufficient. The service will have a responsibility to decide which people identified as being at risk can benefit from which intervention, and then make that intervention available. They also contribute to drawing people at risk into their services, and helping them to use the interventions properly when they have access.

Benefit from evidence based interventions across populations (not to scale) Have the problem Eligible for intervention Aware of problem A B Active use of systems Optimal intervention C D Chris Bentley 2012

However, in order to address the whole ‘decay’ pathway, it will be necessary to recruit other partners. This might include community based organisations, and other parts of the Third Sector as well as other public sector organisations with frontline staff in communities.

Benefit from evidence based interventions across populations (not to scale) Have the problem Eligible for intervention Aware of problem A B Active use of systems Optimal intervention C D Chris Bentley 2012

A. Defining and reaching out to the vulnerable creating a ‘list-of-lists’ virtual register of most at risk

List-of lists • In order to systematise access to the 9 key interventions, a register of the identified most vulnerable people will be needed • This can be a ‘virtual’ register, whereby: – frontline staff identify the most vulnerable on their own caseloads, and establish their own list – A (Cold Weather Plan) co-ordinator compiles a register of staff across the agencies keeping such a list (but doesn’t need the patient/client names) – This ‘list-of-lists’ constitutes the virtual register

Constructing the ‘List-of-lists’

B. Screening for risk and the ability to benefit systematic checklist of uptake on the 9 key interventions

Vulnerable Resident Stroke Association Snow Angels Age UK Fire and Rescue Benefits Agency Housing Social Care Community Care Primary Care Commissioning Organisations

However, the potential is for ……. • The HWB could establish a coordinating sub-group, or assign responsibility for this programme to an existing sub-group. In some areas this has been an expanded Affordable Warmth sub-group, in others the Seasonal Excess Deaths or Cold Weather Planning Group. In the latter cases, there have been strong links to the Local Resilience Forum • In order to drive strong integrated actions, the sub-group might assign or appoint a dedicated programme coordinator • Under the auspices of the HWB structure commissioning agreements to be reached whereby each vulnerable older person has a named key worker, out of those already involved • This could be, for example: – a district nurse – a home care worker from social care or – a voluntary sector advocate

Health and Wellbeing Board EWD Task Group Key Worker Vulnerable Resident

And, once established ……. • Each key worker would be empowered, supported and have the necessary arrangements to: – Carry out a simple screening assessment of uptake on the 9 key interventions – Where appropriate, be able to make a straightforward referral for more detailed assessment and delivery of any missing interventions – Keep a simple record of progress against each of the 9 for his/her ‘list’ – Make a regular return to the co-ordinator/keeper of the list-of-lists

Assessment of vulnerable elderly against 9 interventions Thermal efficiency Household income Falls assessment Vaccinations Medication review Nutrition hydration Assistive technology Patient A GP ------ Patient B GP ------ Contingency plan Patient C GP Patient D GP Patient E GP Assessed/No problem Referred/In process At risk Personal resilience

C. Quality service inputs what good looks like for 8 of the interventions

Co-ordinating delivery • Responsibility for delivery of each of the 9 key interventions would largely continue through specialty agencies as now • Focus would need to be on the connectivity (‘wiring diagram’) amongst agencies • Arrangements would need to be simple and efficient; e. g. single point to receive referral; minimalist referral mechanism; feedback updates to referrer at agreed points • Referrals to other agencies requires patient agreement / consent • Commissioners would need to agree target response times, as part of their quality specification • Key workers could support communication with their vulnerable patient/client where necessary

D. Supporting good self management the 9 th intervention – maximising personal assets

Factors influencing older people in keeping warm and well at home Situation or contextual factors Money Age Social connections Housing type and tenure Health Attitudinal factors − − − Making ends meet Thrift Competing priorities Pride Struggling I can manage Thrift Hardiness Stoicism It's my business Mistrust Pride Privacy I'm frightened Privacy Personal safety/ vulnerability I'll stay as I am Struggle with change Like routine Fear Trust Barriers Awareness Knowledge Information Experience Technology Heating Information Banking Disjointed systems Fragmentation or services Local differences Lack of referral systems Visibility Fuel Money Information Older people KWILLT

Intermediate Outcomes

Summary • A strong case can and should be made to commissioners that deaths, illness and misery of severe winters are largely preventable. • There is a substantial financial case to also take into account, and this emphasises the key impact of mental ill health. • It is proposed that a virtual register of the most vulnerable in an area be established, possibly as a ‘list-of-lists’ • A checklist of evidence-based key interventions should be established, and co-ordinated mechanisms set up to ensure those on the lists are systematically assessed for all • ‘Organised efforts of society’ working together will be necessary to reduce ‘decay’ in access to and use of services by the most vulnerable. This will be necessary to achieve improvements in population level outcomes